Fighting This Hidden Hospital Policy Helped My Mom Save Thousands of Dollars

Being admitted to the hospital doesn't guarantee insurance coverage. Here's what you need to know to avoid getting stuck with a huge bill.

coupleCourtesy Elisa RolandMy biggest question after a fall landed my 80-year-old mother in the hospital should have been will she be okay? Instead it was: How is she going to afford to pay? It’s not as if she didn’t have health insurance. Both she and my 89-year-old father had Medicare. Combined with the supplemental gap insurance they purchased, they were covered for most doctors visits and their various prescriptions. But that chilly November day I learned a sneaky little policy—among other secrets health insurance company won’t tell you—that keeps over 50,000 Medicare patients a year from going to rehab, according to a 2015 AARP Public Policy Institute report. It’s called “observation status.” And Medicare isn’t picking up your tab for it. That could end up being thousands of dollars for the many elderly folks who need treatment in a rehab facility.

According to the Philadelphia Inquirer, Medicare beneficiaries had nearly 620,000 hospital stays for a minimum of three nights that were considered under “observation status” and therefore didn’t quality for benefits. Medicare requires a three-night inpatient stay to merit coverage. And appealing after the fact was not an option until now, as reported by the New York Times. A federal judge in Connecticut certified a class-action lawsuit that may change all that. If the lawsuit prevails as far back as 2009, patients may be able to appeal their observation-outpatient stays and be reimbursed by Medicare.

“People call in dire situations, and we have to tell them there’s no way to challenge this,” said Alice Bers, litigation director of the Center for Medicare Advocacy, which brought the lawsuit with Justice in Aging and a law firm, Wilson Sonsini Goodrich & Rosati. “Now we can tell them, ‘You’re a member of the class, so stay tuned.'”

In my mother’s case, she couldn’t walk and was in great pain, but was not admitted as an inpatient. The hospital case worker assigned to her was empathetic, and we were told she could appeal. Unfortunately her appeal was denied by Livanta LLC who is authorized by Medicare to review medical care and service.

Here’s an excerpt from a letter with Livanta’s independent physician reviewer denying the appeal:

“The patient refuses to walk and according to the hospital paperwork is cleared for discharge. Admission is not medically necessary. Patient would benefit from sub acute placement. Acute hospital level of care not necessary. Care in question did not meet professionally recognized standard of healthcare.”

This denial also meant that if my mother remained in the hospital she would be liable for the bill.

“How can she come home?” my father asked. “I can’t care for her.” And how will she even get in the house? There were two staircases she’d have to climb in their bi-level home. I imagined both my parents falling down the stairs and ending up in the hospital.

Releasing my mother to a rehab facility without Medicare meant I needed to find an open bed on my own. Tough to do on a Saturday evening, and Medicare wouldn’t cover a medical transport home.

What now?

I had to advocate for my parents:

  • I immediately put in a second appeal with Livanta.
  • I made sure I was loud and clear about both my parents’ situation. Letting them know that my father’s macular degeneration and age made him unsuitable to be her caregiver, and that their living arrangements put her at risk for another fall. I made sure to remind them that she couldn’t walk (not that she’d refused) and the amount of pain she was in.
  • I demanded that my mother receive further tests. For instance, even though she hit her head, she hadn’t been evaluated by a neurologist.
  • I spoke with her primary doctor and asked him to advocate for her.

Livanta called the next day. The second appeal was approved. I bawled not because I knew my mother would get better, but because she was at least going to get the health care she deserved—without going into debt to cover it.

Here’s an excerpt from the second letter approving my mother’s appeal:

“I would agree that admission was necessary and that any reasonable physician would manage this patient by admitting her for testing and treatment considering her safety issues.”

It took my mother over three weeks to learn to walk again with the aid of a walker. But it’s taken me much longer to have faith in our health care system again.

Don’t miss the 50 secrets hospitals won’t tell you—but you’ll want to know.

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